Summary On the afternoon of 12 September 2005, the small fishing vessel MelinaKeithII, with eight persons on board, was hauling nets off Funk Island Bank, Newfoundland and Labrador. The vessel took on water through the side fishing door and subsequently capsized in approximate position 4855.5'N, 05117.5'W. Four persons were rescued and the body of a deceased crew member was recovered; three crew members are missing and presumed drowned. Ce rapport est galement disponible en franais. Other Factual Information Description of the Vessel Photo1. The MelinaKeithII following the work deck enclosure The MelinaKeithII was a small fishing vessel of closed construction, with an all steel, welded double-chine hull. The hull below the main deck was subdivided by transverse watertight bulkheads, enclosing a forepeak, water tanks, engine room, fish hold, cofferdam, fuel tanks, and lazarette. Crew accommodation forward and an extended shelter deck aft were located on the main deck, and the wheelhouse was one deck above the accommodation. A single weathertight door led from the accommodation onto the main deck aft, to starboard of which was a galley window. A hauling side door was fitted on the starboard side shell in way of the shelter deck. The MelinaKeithII was one in a series of 65-foot fishing vessels, the first of which was built in 1982. Although similar in basic design, various modifications have been incorporated by individual owners. The MelinaKeithII was originally built with a work deck that was open to the environment. Due to the nature of the vessel, seas were frequently shipped, making for hazardous conditions on the work deck. The deck was fully enclosed in2000, and four submersible pumps were installed for dewatering. The MelinaKeithII was originally built as a longliner, but had undergone modifications over the years to become a multi-purpose vessel, capable of stern trawling or fishing fixed gear such as gill nets and long lines. These modifications included the following: installation of an A-frame on the stern; installation of winches on the shelter deck; fitting of stabilizers on the port and starboard quarters; full enclosure of the weather deck, enabling it to be made weathertight; installation of submersible sewage pumps on the weather deck for dewatering the enclosed deck; welding shut of the freeing ports; reconfiguration of the accommodation to house a crew of 12; enlargement of the wheelhouse; fitting of a steel railing around the perimeter of the monkey island (wheelhouse top), except for a small opening in the after area. While the three railings on the port side were continuous, only the top pipe rail on the starboard side was continuous; the bottom two were cut out to a size that would allow a liferaft to pass through. The wheelhouse was fitted with communication and navigation equipment including VHF radiotelephone with digital selective calling (DSC) a vessel monitoring system (VMS) satellite telephone cellular telephone echo sounder/fish finder radars History of the Voyage On 06 September 2005, the MelinaKeithII departed Catalina, Newfoundland and Labrador, for a turbot and shrimp fishing trip with a crew of seven, plus a fisheries observer. The vessel was participating in a test fishery for turbot. On the way to the shrimp fishing grounds, the vessel stopped to haul the gill nets. While stowing the turbot, a crew member sustained an injury to his hand and was thereafter unable to assist with the fishing operations. After hauling the 125gill nets and stowing about 4500kg of turbot and 725kg of by-catch, the MelinaKeithII reset the gill nets and steamed northeast for about 80nautical miles (nm) to fish for shrimp. By the morning of September11, after three days of fishing, the vessel had over 27000kg of shrimp, filling 11of the 15pens in the hold. The remaining hold space consisted of two pens half full of turbot, one pen half filled with ice, and one with 725kg of by-catch. By the time the final haul of shrimp was taken back, the wind had increased from moderate to 40to 45knots from the northeast. The MelinaKeithII began to slowly make its way back toward the turbot gill nets in anticipation of hauling them in the morning before returning to port. At 0900 Newfoundland daylight time3 on September12, the crew members were awakened and called on deck to prepare the vessel for working the nets. At 1140, they began to haul the first fleet of 40gill nets. The wind had subsided to northeast 15knots, and the waves were estimated at 2m. The skipper was in the wheelhouse, and the crew and the observer were on deck, with the exception of the previously injured crew member, who was in the galley. While retrieving the nets, the vessel had a starboard list, and waves splashed in through the open hauling door on the starboard side, soaking the crew. Getting wet while hauling gear was not considered out of the ordinary. The skipper came down on deck to help the crew haul back the gear and pick out the fish, while manoeuvring the vessel using the remote controls by the hauling door. As the nets came on board, the turbot was picked out and placed in a box on the port side of the centreline, and the gear was stowed on the vessel's starboard quarter. Unsuccessful attempts were made to move some gear to the port side. With over half of the nets of the fleet recovered, the vessel took a moderate roll to starboard and shipped about 5cm of water on deck, which the pumps were able to manage. The vessel recovered, but then took another moderate roll to starboard, shipping about 15to 20cm of water. The vessel did not recover after this, and the submersible pumps could not keep up. Listing heavily, the vessel had a water depth of 20to 25cm on the starboard side. The net hauler was stopped, the vessel taken out of gear and the skipper ran to the wheelhouse to check for alarms and to study the video monitors, which provided information from remote cameras located in various sections of the vessel. Seeing no water below decks on the video monitors, he began retrieving immersion suits from the wheelhouse storage locker. Shortly after the skipper left the fishing deck, the vessel took another heavy roll; this time, water poured in steadily through the hauling door. The persons on deck made their way to the outside of the wheelhouse on the port side. The crew member in the galley made his way to the wheelhouse via the accommodation, where he encountered the skipper. The two exited the wheelhouse where the skipper partially donned an immersion suit. With the MelinaKeithII heeling heavily, all personnel assembled on the port side and stood on the side of the wheelhouse. The crew attempted to manually release the liferaft mounted on the port side of the wheelhouse top, but as it was overhead and behind the rails, they could not. Events Following the Capsizing At about 1529, the vessel was on its beam ends and it continued to roll until it was completely upside down. As it rolled, all eight of the personnel walked over the vessel's side until they stood on the bottom. The vessel's emergency position-indicating radio beacon (EPIRB) was seen floating with its light flashing after the vessel capsized. The personnel remained on the bottom of the overturned boat for two hours before the vessel sank in estimated position 4855.5'N, 05117.5'W. As the vessel slipped below the surface at 1740, the personnel jumped in the water, but two were non-swimmers and disappeared almost immediately. No debris surfaced until 10minutes later when the vessel's aluminum workboat floated to the surface. Four persons clung to the aluminum boat, but, when two pieces of styrofoam also floated up, two crew members left the boat and held onto the styrofoam. The skipper was floating in his immersion suit, and another crew member found a board to hang onto. One of the crew members holding onto the aluminum boat slipped under the water after about 45minutes and was not seen again; the other held on, putting his arm through a hole in the bow. The five remaining persons were in the water for about 90minutes, until a fishing boat appeared. Four persons were rescued, but the fifth succumbed about 15minutes before the vessel arrived on scene. Search and Rescue The EPIRB began transmitting shortly after the vessel capsized, and its 406MHz emergency signal was received from a high-altitude geostationary operational environmental satellite (GOES)4 by the Canadian Mission Control Centre (CMCC) in Trenton, Ontario, at1532. The information from this satellite and the Canadian Beacon Registry, which was limited to the vessel's name and contact information, was sent to the Joint Rescue Coordination Centre (JRCC) Halifax, Nova Scotia, and then forwarded to the Maritime Rescue Sub-Centre (MRSC) St. John's, Newfoundland and Labrador, at1536. The following is an abridged version of search and rescue (SAR) activities: At the time of the occurrence, there was one SAR coordinator on duty at the MRSC. There is a high false alarm rate associated with EPIRBs and the SAR coordinators must investigate a distress beacon for authenticity. This requires contacting the person(s) identified as 24-hour contacts on the EPIRB registration form to determine if the vessel is at sea and, if so, its location. In this case, the SAR coordinator made 14calls to the two 24-hour contact numbers - a home residence and a cell phone. No one responded to these calls at either number. Injuries to Persons Four persons were rescued. One crew member drowned; his body was recovered, and the three others are missing and presumed drowned. Certification The MelinaKeithII was subject to quadrennial Transport Canada (TC) inspections in accordance with the Small Fishing Vessel Inspection Regulations (SFVIR). The vessel was last inspected in August2004 after a lengthy refit following a shipboard fire in2003. The skipper, who had been on fishing boats since he was a youth and was considered an experienced fisher, held a fishing master, second-class certificate, which exceeded the TCregulations for the voyage limits of home-trade, ClassI required on this vessel. Although TCregulations required a mate with a minimum fishing master, fourth-class certificate, there were no other certified crew members on board. Three of the four survivors had marine emergency duties (MED) training; it is unknown if the other four crew members had. Weather Winds were from the northeast at 10to 15knots, with 2m seas. The air temperature was 14C and sea temperature was 14C. Pumping Arrangement for the Shelter Deck The MelinaKeithII was fitted with four bilge wells, each with a submersible sewage ejector pump. The wells were located in the four corners of the enclosed fishing deck. Two pumps were capable of pumping 7.3litres of water per second, while two larger ones could pump 8.2litres persecond. Stability Stability Requirements for a Small Fishing Vessel As a small fishing vessel not exceeding 150tons, gross tonnage, and not exceeding 24.4 m in length, the MelinaKeithII was subject to the requirements of the SFVIR. The owners were not required to submit stability data for approval because the vessel was used to fish for shrimp, crab, or groundfish. This is in contrast to vessels of the same size that were employed in catching herring or capelin, which must submit stability data for TC's approval. The minimum criteria for determining the stability of these vessels is STAB4 of the TCpublication Stability, Subdivision and Load Line Standards (TP7301). In 2000, the MelinaKeithII underwent major modifications that adversely affected its stability. TC did not request a stability assessment following the 2004quadrennial inspection, nor did the owner. Factors Affecting Stability As the MelinaKeithII was not inclined, no stability data were available to assess its transverse stability. Most of the modifications carried out over the years resulted in additional weight added to the original lightship displacement and were located above the original centre of gravity, reducing the vessel's inherent transverse stability. The vessel had an inherent starboard list, likely due to some fixed asymmetrical weights. Unless the liquid in tanks was asymmetrically loaded to compensate, this list was permanent. This reduced the potential righting energy of the vessel on the heeled side. On the day of the occurrence, the vessel was heavily laden with shrimp, fish, and ice. The after fuel oil tanks were partly filled, the forward fuel oil tanks were full, the fresh water tank was partly filled, and the water ballast tanks were full, thereby reducing the freeboard. The load in the fish hold was unevenly distributed: 10886kg, 13608kg, and 8165kg of fish, shrimp, and ice were distributed in the port, starboard, and centre pens respectively. This distribution created a heeling moment, and the corresponding starboard angle of heel added to the permanent list. The force resulting from hauling the gear through the side door contributed further to the starboard list. While retrieving the nets, the vessel had a starboard list and reduced freeboard. Waves entered via the opened hauling door on the starboard side. As the nets came on board, the turbot was picked out and the gear was stowed on the vessel's starboard quarter. This increased the heeling moment and the angle of heel, further reducing the vessel's transverse stability. Lifesaving Equipment Lifejackets were stowed in forward accommodation cabins, immersion suits were carried in a locker in the wheelhouse, and vests and floater suits were reportedly stowed in a deck locker. At the time of the occurrence, no crew members wore lifejackets or personal flotation devices (PFDs), and only the skipper was wearing an immersion suit. The vessel was equipped with an eight-person and a ten-person inflatable liferaft, both of which were fitted with hydrostatic releases. There was also a five-person aluminium rowboat on board. Liferafts are commonly stowed on top of the accommodation and wheelhouses of fishing vessels. On the MelinaKeithII, the liferafts were on either side of the wheelhouse top and abutting the railing. The vessel's crew attempted to free the port liferaft but were hindered by the railing and were unable to do so. The Board has previously addressed shortcomings in liferaft stowage and accessibility and issued Recommendation M93-03. In response, TCissued Ship Safety Bulletins (SSBs) 09/1993 and 03/2001, highlighting the recommended practice for the stowage of throw-over type inflatable liferafts. One recommended practice was that liferafts should be stowed such that, when lifted from their cradles, they can be deployed over the side of the vessel. In addition, TCinitiated a study (March1998) to consider methods of improving the stowage of lifesaving equipment on board fishing vessels. One objective was the development of a low-maintenance, cost-effective, safe, and efficient system for the stowage and deployment of small liferafts. However, the study was never completed. In the proposed Fishing Vessel Safety Regulations, anticipated to be completed in2008, TCintends to pursue provisions that will require all liferafts to be stowed such that they will float free if a fishing vessel capsizes and sinks. Distress Alerting Distress-alerting equipment on board included a Class1, 406MHz EPIRB, a DSC-enabled VHF and a Global Maritime Distress and Safety System (GMDSS)-compliant satellite communication system (Sat-C), incorporated with the VMS, capable of sending a distress alert. The vessel also had a portable satellite telephone and a cellular telephone. Emergency Position-Indicating Radio Beacon The EPIRB floated free and transmitted the distress alert as designed. EPIRB signals sent to the Cospas-Sarsat system are used in roughly one real distress and safety incident per day worldwide.5 However, statistics gathered in 2003show that false distress alerts for the 406MHz beacon are about 95percent worldwide. Furthermore, it can take the Cospas-Sarsat system up to 90minutes to pinpoint the beacon's signal. In this occurrence, the signal was picked up within minutes by a GOES satellite, but it was not until1644, or 72minutes later, when the Sarsat satellite picked it up, that a position was known. The initial GOES satellite hit from the MelinaKeithII's EPIRB resulted in only the name of the vessel and two contact numbers. In many cases, with a simple telephone call, a vessel that has inadvertently set off an alarm can be found tied up in port. The Canadian National Search and Rescue Secretariat's (NSS) EPIRB registration form has space to enter two telephone numbers (that is, home and office). Neither is specified as an emergency contact. On the back of the form, in small print, is written: Give area code and number(s) where you can be reached 24hours a day. By contrast, the United States EPIRB registration form provides four spaces for Primary 24-Hour Contact numbers as well as four for Alternate 24-Hour Contact numbers - all in a section titled Emergency Contact Information. This section specifies that such numbers must be for someone other than the owner. An additional four spaces are provided elsewhere on the form for contacting the owner/operator. Digital Selective Calling Radio and Vessel Monitoring System Neither the DSC radio nor the Sat-C distress alerts were manually activated. Neither the satellite nor the cellular telephones were used. A distress alert on a DSC radio is transmitted in about five seconds and accidental activation is unlikely. In Newfoundland and Labrador, the Department of Fisheries and Oceans (DFO) implemented mandatory VMS coverage for most major domestic fisheries in 2004for the purpose of fisheries management. A VMS allows the DFO to enhance its fisheries surveillance and enforcement capabilities, making a considerable contribution to the overall management of the fishery and providing additional data in support of science research. A VMS allows fishing vessel positions to be transmitted to DFO at regular intervals via a satellite communication system. The information is then relayed to a monitoring centre. Activating the associated distress button causes the transmission of a distress alert that contains the vessel's identity, the time, and positional information. The Inmarsat-C system assigns the highest level of priority to distress alerts and distress messages. Alerts are forwarded without delay from the Land Earth Station to the specified JRCC. At the time of the occurrence, all SAR coordinators at MRSC St. John's had received formal and informal training on the Search Mission Management System (SMMS) and VMS, but the duty SAR coordinator never had the occasion to use the VMS to locate a distressed vessel. Familiarization and Emergency Drills There is no indication that the crew had received safety familiarization on the vessel or that emergency drills were regularly practiced. Some crew members did not know where the immersion suits were located.